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Review
. 2023 Jul 19;15(14):3670.
doi: 10.3390/cancers15143670.

Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases

Christian D Diehl  1   2   3 , Frank A Giordano  4 , Anca-L Grosu  5 , Sebastian Ille  6 , Klaus-Henning Kahl  7 , Julia Onken  8   9   10 , Stefan Rieken  11   12 , Gustavo R Sarria  13 , Ehab Shiban  14 , Arthur Wagner  6 , Jürgen Beck  15 , Stefanie Brehmer  16 , Oliver Ganslandt  17 , Motaz Hamed  18 , Bernhard Meyer  6 , Marc Münter  19 , Andreas Raabe  20 , Veit Rohde  21 , Karl Schaller  22 , Daniela Schilling  1   2 , Matthias Schneider  18 , Elena Sperk  23 , Claudius Thomé  24 , Peter Vajkoczy  8 , Hartmut Vatter  18 , Stephanie E Combs  1   2   3
Affiliations
Review

Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases

Christian D Diehl et al. Cancers (Basel). .

Abstract

Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.

Keywords: brain metastases; intraoperative radiation therapy; microsurgical resection; neurosurgery; radiosurgery; stereotactic radiation therapy; whole brain radiation therapy.

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Conflict of interest statement

C.D.D.: Consulting fees and travel expenses from Carl Zeiss Meditec AG. S.B.: Honoraria, travel, and accommodation expenses from Carl Zeiss Meditec AG. F.A.G. has received or receives research grants, personal fees, and/or travel expenses from Carl Zeiss Meditec AG, personal fees from Roche Pharma AG and Medac, grants and personal fees from AstraZeneca, Bristol-Myers Squibb, Cureteq AG, Elekta AB, FoMF GmbH, Guerbet SA, MSD Sharp, Dohme GmbH, and Opasca GmbH, stocks, grants, and personal fees from TME Pharma AG (formerly Noxxon Pharma AG), compensation for advisory boards from the Federal Joint Committee (G-BA) of the Federal Republic of Germany and of the German Cancer Aid, and non-financial support from Oncare GmbH and Opasca GmbH. A.-L.G.: Grant from Novocure GmbH. K.-H.K.: Honoraria, travel, and accommodation expenses from Varian Medical Systems, Elekta AB, Carl Zeiss Meditec AG, Bristol–Myers Squibb, MSD Sharp and Dome, AstraZeneca, Merck KGaA, Roche, Sanofi-Aventis, and Icotec AG. B.M. received honoraria, consulting fees, and research grants from Medtronic (Meerbusch, Germany), Icotec AG (Altstätten, Switzerland), and Relievant Medsystems Inc. (Sunnyvale, CA, USA); honoraria and research grants from Ulrich Medical (Ulm, Germany); honoraria and consulting fees from Spineart Deutschland GmbH (Frankfurt, Germany) and DePuy Synthes (West Chester, PA, USA); and royalties from Spineart Deutschland GmbH (Frankfurt, Germany). S.I. and B.M. are consultants for Brainlab AG (Munich, Germany). SI is a consultant for Icotec AG (Altstätten, Switzerland) and has received honoraria from Nexstim Plc (Helsinki, Finland) and Carl Zeiss Meditec (Oberkochen, Germany). J.O.: Consulting fees and travel expenses from Carl Zeiss Meditec AG. V.R.: Consulting fees and travel expenses from Carl Zeiss Meditec AG and Karl Storz. G.R.S.: Honoraria, travel, and accommodation expenses from Carl Zeiss Meditec AG. Honoraria from MedWave Clinical Trials. Travel and accommodation expenses from Guerbet SA. D.S.: Consulting fees and travel expenses from Carl Zeiss Meditec AG. E.S. (Ehab Shiban): Honoraria for oral presentations, travel expenses from Carl Zeiss Meditec AG. E.S. (Elena Sperk): Honoraria for oral presentations, travel expenses from Carl Zeiss Meditec AG. C.T.: Consulting fees, honoraria, and travel expenses from Carl Zeiss Meditec AG. S.E.C.: Grant, contracts, consulting fees, honoraria, travel, and accommodation expenses from Roche, Bristol-Myers Squibb, Brainlab, AstraZeneca, Accuray, Dr. Sennewald, Daiichi Sankyo, Elekta, Medac, Icotec AG, HMG Systems Engineering, and Carl Zeiss Meditec AG. J.B., O.G., M.H., M.M., A.R., S.R., K.S., M.S., P.V., H.V. and A.W. report no conflict of interest.

Figures

Figure 1
Figure 1
(A) Connection of the spherical applicator with the X-ray source and sterile draping; (B) Manual applicator positioning into the resection cavity; (C) Intraoperative view of the inserted applicator in the resection cavity; (D) Intraoperative set-up prior to the start of IORT.
Figure 2
Figure 2
Three-dimensional view of dose distribution profiles, comparing (A) IORT and (B) SRS for the same target. Reprinted with permission from Sarria et al. [181]. Copyright year 2021, copyright owner’s name Sarria et al. Under the terms of the Creative Commons Attribution License (CC BY) [181].
Figure 2
Figure 2
Three-dimensional view of dose distribution profiles, comparing (A) IORT and (B) SRS for the same target. Reprinted with permission from Sarria et al. [181]. Copyright year 2021, copyright owner’s name Sarria et al. Under the terms of the Creative Commons Attribution License (CC BY) [181].
See this image and copyright information in PMC

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